Updated: Oct 17
A missing tooth clause is a fine print stipulation in your insurance contract that may exclude you from certain dental benefits. The affected benefits often involve the replacement of a missing tooth, hence the name.
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What is a missing tooth clause?
The missing tooth clause is similar to a "pre-existing condition" for medical insurance. The purpose of both of them is to deny you benefits which means you will be responsible for the entire bill out of pocket.
This is what the clause states: If you have a missing tooth prior to signing up with the dental insurance, you will not have benefits to replace that missing tooth.
What the missing tooth clause means for you:
You will only have tooth replacement benefits if you the tooth is extracted while you're actively eligible on the insurance plan.
However, if the tooth was extracted before getting the insurance, you will not have replacement tooth benefits.
Why is this important to you?
It is important to be aware of the presence of this clause in your dental insurance contract in case you are someone with a missing tooth.
According to studies, the prevalence of tooth loss for adults between 20-64 years old was about 35.7%.
It gets worse if you look at the population over 65 by the CDC:
26% have 8 or fewer teeth
17% have lost all of their teeth
Adults who are poor, have less than a high school education, and are cigarette smokers are 3x more likely to lose all of their teeth.
As you can see, it is quite common to be missing teeth, hopefully you're not missing one right now but if you are, you should read the insurance contract fine print carefully. You don't want to end up choosing an insurance plan that has the missing tooth clause. You would be paying money for an insurance that does not cover teeth replacement.
Missing teeth replacement treatments include:
If you have this particular clause in your contract and you try to replace a missing tooth, your insurance claim will be denied. Your dentist can submit it as many times as they want but the claim will return with a footnote stating denial of benefits due to missing tooth clause.
Basically you will receive zero benefits and zero help from your dental insurance when you try to replace the tooth. Ultimately you will have to foot the entire bill yourself.
Dental insurances with a missing tooth clause
Any dental insurance can potentially have a missing tooth clause but it all depends on your specific contract. This stipulation can be included in the contract often as a means of decreasing the insurance premium, thus lowering monthly payments.
Insurances that may have the clause:
Whether or not these dental insurances have it, you will need to read the fine print of the contract carefully. If you are unsure, the best thing to do would be to call the insurance and ask one of the agents directly.
The missing tooth clause affects all dental procedures whose purpose is to replace said missing tooth.
Tooth replacement procedures:
Implant - a fixed replacement option utilizing a medical grade titanium screw.
Bridge - an alternative fixed replacement option that involves crowning the adjacent teeth. It is less conservative than an implant since at least two other teeth need to be shaved down.
Dentures - a removable replacement option with either partial or complete dentures.
Examples of how it may affect you
Various scenarios used to exemplify how having this clause may affect your insurance coverage.
Missing tooth before getting insurance
Scenario: You had a tooth removed before you signed up for the insurance plan. After getting the insurance you try to replace the gap with an implant.
Result: Your insurance will deny the claim. You are responsible for the full cost of treatment.
Missing tooth after getting insurance
Scenario: You signed up for insurance first and then had a tooth extracted using the insurance. Now you're trying to replace the space with a bridge or implant.
Result: Your insurance must take your claim into consideration since the tooth was missing after you had insurance.
Changing insurance during the process
Scenario: Your insurance has a missing tooth clause so you wait to extract the tooth after you sign up for it. However, you changed your job after the extraction and received a new insurance that also has the clause. Now you're trying to replace the tooth with a bridge.
Result: The bridge will be denied since the new dental insurance has the clause. You should be wary of switching insurances in the middle of the process or at least take it into consideration.
How can you avoid this situation if you were unaware?
You can avoid having to be stuck with a large dental bill by having your dentist submit a predetermination prior to beginning any dental treatment. A predetermination is usually recommend for any major dental procedure.
Major work is defined as:
Dental crowns, tooth caps
Complete dentures are also included
There is absolutely no reason not to submit a pre-approval. It is only to your benefit. The only downside is that it usually takes about 2 weeks to hear back from your insurance regarding their decision to cover the procedure or not.
How do I check if I have this pre-existing condition clause?
There are two ways to find out if you have this fine print in your insurance plan:
Call the insurance company and ask
Ask your human resource (HR) department
The first one is self explanatory but the second one, most people miss. Why would your HR know? That is simple, your HR actually helped your company negotiate for the insurance benefits so they would know if it was included or not. They should've been the one to help guide you in choosing the right insurance for your needs.
How to appeal the insurance denial
Unfortunately, all appeals for insurance denials due to a missing tooth clause will fall on deaf ears. The appeals never get overturned because the clause was in the contract when you signed it. It was there all along, you just never read it or never asked about it.
You cannot overturn wording that is set in stone since the beginning from a legal contract. That is why it is important to know of this stipulation and ask about it prior to purchasing the insurance.
Now that you know, please ask a lot of questions before you just sign up for a dental insurance. Make sure that it has coverage for the procedures that you will need. The missing tooth clause gets a lot of people! Basically if you were missing a tooth before your insurance is active, you will have no coverage for any of the replacement procedures!
Do you know what is another one, which gets people? Your dental insurance has orthodontic coverage but only for those age 19 and under!
Well, when in doubt you can always ask all of your questions at your dental check up appointment.